Fear of falling Fall-related psychological difficulties that often result from a fall should be investigated and screened for by clinicians. Fear of falling, poor falls efficacy, and/or poor balance confidence are common consequences of past falls or near falls. Fear of falling can be defined as a “lasting concern about falling that leads to an individual avoiding activities that he/she remains capable of performing” (Tinetti & Powell, 1993). Falls efficacy refers to the confidence in one’s ability to perform ADLs without falling (Tinetti et al., 1990). Balance confidence is defined as the “confidence in one’s ability to maintain balance and remain steady” (Powell & Myers, 1995). There are several assessment tools designed to measure one or more of these three psychological consequences of falls, with no real consensus on the best tool to use. A review of the literature by Moore and Ellis identifies the Falls Efficacy Scale (FES; Tinetti, et al, 1990), ABC (Powell & Myers, 1995), and the Survey of Activities and Fear of Falling in the Elderly Scale (SAFFE; Lachman et al., 1998) as the three most widely used instruments (Moore & Ellis, 2008). There are shorter, modified versions of each of these and no clear choice based on reliability or validity. A newer assessment, the Falls Efficacy Scale International (FES-I; Delbaere et al., 2010), has a 16-item and a 7-item version and shows good validity and reliability, although cut-points and responsiveness to change over time are still under investigation. Thus, the two instruments of choice based on ease of completion are the FES (>70 indicates a fear of falling; Tinetti, et al, 1990) and the ABC (<67% = older adults at risk for falling; predictive of future fall; Lajoie & Gallagher, 2004). Either of these instruments should be used to determine if an older adult is avoiding ADLs due to apprehension surrounding falls. Asking a yes/no question on fear of falling (e.g., “Are you fearful of falling?”) may indicate when the full scale should be used. This may work better for women than men (Myers et al., 1996). Frailty Clinicians should note the presence of frailty in older adults who are at least 75 years of age or who may show signs of becoming frail. Frail older adults, especially women, are at increased risk for recurrent falls, hip fracture, any non-spine fracture, and death (Ensrud et al., 2007). Thus, it is important to evaluate for the presence of this condition. Although there is not gold standard model for assessing frailty, using a model like the Fried frailty model described earlier would be a good addition to an evaluation of an older adult who is suspected of being frail, such as residents in a long-term care facility. Using
a five-item model would allow a clinician to define pre-frail as having two of five factors, frail as having three of five factors, and severely frail as having four or five of five factors. Suggested factors could be balance, gait speed, fall history, grip strength, or leg strength. These are all physical factors related to frailty. Other models include cognition, incontinence, or depression. Although multicomponent interventions have superior outcomes when combating frailty, the optimal time to intervene appears to be in the pre-frail stage (Cadore, Rodriguez-Manas, Sinclair, & Izquierdo, 2013). Environmental hazards Environmental risk hazards were cited in Table 1 as extrinsic fall risk factors. In the 2015 National Falls Prevention Action Plan (Cameron et al., 2015), home safety, as it relates to fall prevention, is one of the four goals intended to reduce fall incidence. The other three goals are physical mobility, medication management, and environmental safety in the community. Checking for home and environmental hazards is also a recommendation in the AGS/BGS clinical guidance statement (AGS/BGS, 2015). Handouts on home safety surveys are included in the STEADI fall prevention materials and there is good evidence for use of safety assessments in a multifactorial fall risk assessment and as part of an intervention plan (CDC/ STEADI, 2017). The STEADI “Check for Safety” brochure also prompts older adults to check items such as trip hazards on the floor, lighting, stair safety, and bathroom safety. Home hazard assessments should also include follow-up and modifications as needed in order to be effective. In summary, a thorough fall risk assessment may be triggered after a general fall risk screening. This assessment, at a minimum, should include examination of gait and balance if problems in these areas or reported or observed during the screening. Additional assessments may include tests for strength, ROM, posture, sensation and sensory integration, cognition and dual-tasking, cardiovascular status, fear of falling, frailty, and environmental hazards. These assessments should match the individual’s physical and cognitive capabilities. These physical, cognitive, and environmental areas should be assessed based on individual presentation and clinician decision making. Regarding fall risk assessment, additional questions should be asked by the assessing clinician or primary caregiver related to other fall risk factors such as osteoporosis, incontinence, alcohol use, depression, and vitamin D insufficiency, as described earlier in Table 1 (Phelan, Mahoney, Voit, & Stevens, 2015).
DESIGNING INTERVENTIONS TO PREVENT FALLS
This section will address fall prevention programs that have been proven to work and are supported by research, existing Evidence-based components of a fall prevention intervention Successful fall prevention interventions include multifactorial components, are salient to the older adults, and result in good compliance with attendance to exercise or educational sessions as well as exercise at home on the recommended schedule (Avin et al., 2015). According to the Academy of Geriatric Physical Therapy CGS, fall prevention programs should include gait, balance, home safety, and attention to foot problems and safe footwear, and should include educational information on fall risk factors specific to the individual (Avin et al., 2015). For an older adult with a history of falls, understanding the need to prevent future falls may be fairly easy. For adults without a fall history, convincing them that they may be at risk requires more objective evidence and education. Getting buy-in from the older adult who considers their fall history to be a one-time only accident also may be challenging. In a study by Porter, Matsuda, and Lindbloom (2010), women who had fallen in their home tied any future intentions of preventing falls to the situation that “caused” the original fall. They failed to generalize risk for falling again to any other situations other than the specific fall situation. These researchers suggest that clinicians ask older
guidelines for fall prevention programs, and recommendations for key actions that can prevent future falls.
adults about their intentions to prevent future falls, so that they can address the need to generalize fall risk factors to multiple settings and challenges. Many fall risk factors potentially influence the chance of falling in multiple settings, not just in the adult’s home on a certain carpet or particular set of stairs. Adults who have developed avoidance behaviors because of lack of balance confidence or fear of falling may be more compliant with the suggested program if they understand that completing the entire program will get them back into the community and social activities, driving, or being generally more independent (Yeom, Keller, & Fleury, 2009). Fall prevention education should include examples salient, or important and specific, to that person. Salience is a key to improved exercise compliance with older adults (Robinson, Newton, & Jones, 2014; Shumway-Cook & Woollacott, 2007). Some programs also use exercise logs, fall diaries, and/or phone call check-ins to encourage compliance with the prescribed program. For older adults, the social aspects of a group exercise class also can increase compliance and enjoyment in the fall prevention program (Garmendia et al., 2013).
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